Management of direct oral anticoagulants in patients undergoing elective surgeries and invasive procedures: Updated guidelines from the French Working Group on Perioperative Hemostasis (GIHP) – September 2015 - 21/02/17

Doi : 10.1016/j.accpm.2016.09.002

Pierre Albaladejo ^a,^⁎ , Fanny Bonhomme ^b, Normand Blais ^c, Jean-Philippe Collet ^d, David Faraoni ^e, Pierre Fontana ^f, Anne Godier ^g, Juan Llau ^h, Dan Longrois ⁱ, Emmanuel Marret ^j, Patrick Mismetti ^k, Nadia Rosencher ^l, Stéphanie Roullet ^l, Charles-Marc Samama ^m, Jean-François Schved ⁿ, Pierre Sié ^o, Annick Steib ^p, Sophie Susen ^q
the
French Working Group on Perioperative Hemostasis (GIHP)
^a Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble-Alpes, 38043 Grenoble, France
^b Division of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland
^c Department de Medicine – University of Montréal, CHUM - Hôpital Notre-Dame, Montréal, Quebec, Canada
^d Univ Paris 06 (UPMC), ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (APHP), Paris, France
^e Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, USA
^f Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
^g Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
^h Department of Anesthesiology and Critical Care. Hospital Clínic Universitari, Valencia, Spain
ⁱ Département d’Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, University Paris Diderot, Sorbonne Paris Cité, U1148 INSERM, Paris, France
^j Department of Anesthesiology, American Hospital of Paris & Institut Hospitalier Franco-Britannique
^k Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
^l Department of Anaesthesia and Intensive Care Medicine, Cochin and Hôtel-Dieu University Hospitals, Paris Descartes University, Paris, France
^m Service d’Anesthésie Réanimation 1, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
ⁿ Department of Hematology, CHU Montpellier, Montpellier, France
^o Department of Hematology, Toulouse University Hospital, Toulouse, France
^p Department of Anesthesiology and Intensive Care, University Hospital, Strasbourg, France
^q Department of Hematology and Transfusion, Lille University Hospital, Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France

^⁎Corresponding author.

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Abstract

Since 2011, data on patients exposed to direct oral anticoagulants (DOAs) while undergoing invasive procedures have accumulated. At the same time, an increased hemorrhagic risk during perioperative bridging anticoagulation without thrombotic risk reduction has been demonstrated. This has led the GIHP to update their guidelines published in 2011. For scheduled procedures at low bleeding risk, it is suggested that patients interrupt DOAs the night before irrespective of type of drug and to resume therapy six hours or more after the end of the invasive procedure. For invasive procedures at high bleeding risk, it is suggested to interrupt rivaroxaban, apixaban and edoxaban three days before. Dabigatran should be interrupted according to the renal function, four days and five days if creatinine clearance is higher than 50mL/min and between 30 and 50mL/min, respectively. For invasive procedures at very high bleeding risk such as intracranial neurosurgery or neuraxial anesthesia, longer interruption times are suggested. Finally, bridging with parenteral anticoagulation and measurement of DOA concentrations can no longer routinely be used.

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Keywords : Direct oral anticoagulants, Elective surgery, Periprocedural management